Restraints cited in three deaths at Bridgewater
State hospital’s harsh patient care raises questions about health care provider
BRIDGEWATER — Bradley Burns let out a gut-wrenching howl as he lay strapped hand and foot to a small bed, his torso bound by a tightly wound sheet, his head and eyes covered with a helmet and goggles.
Burns had spent 23 hours a day like that — almost completely immobilized — for 16 months because medical staff at Bridgewater State Hospital felt it was the best way to prevent the sometimes-violent patient with paranoid schizophrenia from hurting himself, or others, as he had in the past. Even for visitors, he was placed in a tiny cell with barely enough room to stand or sit.
“It was like the cage with Hannibal Lecter,” his lawyer, Bernard Grossberg, recalled.
On this day, May 31, 2010, the care intended to protect the 34-year-old Burns may have killed him instead. Racked by excruciating back pain, he abruptly stopped breathing, likely because of a heart arrhythmia brought on by his medications and the restraints on his movement, the state medical examiner found.
His little-publicized death was anything but isolated at Bridgewater, the state’s prison for people with mental illness. Three years later, 45-year-old Paul Correia died from a blood clot that the medical examiner found was likely exacerbated by spending the better part of three days strapped to a bed.
And both Burns and Correia died after another patient, Joshua K. Messier, 23, suffered heart failure as guards forcibly placed him in restraints, an encounter caught on surveillance video and ruled a homicide by the medical examiner. But rather than lead to reforms, Messier’s death was a harbinger of things to come.
A Globe review has found that after Messier’s death, the private company that provides medical and mental health care at Bridgewater approved the use of physical restraints with increasing frequency even as two more patients died. Meanwhile, other prisons were moving decisively away from the use of restraints to control agitated mental health patients.
Yet the questionable quality of care provided at Bridgewater by Virginia-based MHM Services did not prevent the company from winning a five-year contract to provide the same services across the state prison system in July 2013. The Massachusetts Partnership for Correctional Health, formed by MHM and St. Louis-based Centene Corp., won the $500 million contract with Bridgewater’s superintendent at the time, Robert Murphy, serving on the selection panel.
And the Massachusetts Partnership has remained in good standing with Department of Correction officials even as bad news about the company’s performance has mounted this year, including five consecutive state audits that found persistent problems in the way its staff cares for patients placed in isolation or restraints. Also, MHM agreed to pay part of a $3 million legal settlement to Messier’s family earlier this year, after the family filed a civil rights lawsuit.
Nonetheless, prison officials have never used provisions in the Massachusetts Partnership’s contract that allows them to fine the company for failing to meet medical and mental health standards. The state had issued nearly $1 million in fines through June for failures to meet prison staffing requirements, but even there, correction officials have agreed to waive almost $400,000 of the penalties.
“They have a stick but they’re just not using it, for whatever reason,” said Lawrence Weiner, a former Department of Correction official who said he was fired a year ago after clashing with agency officials over efforts to make the Massachusetts Partnership comply with the terms of its contract. “And without the fiscal penalties there’s really no incentive for the vendors to correct problems.”
In a statement, department officials insisted they have “set clear expectations for MPCH . . . and put in place a number of specific performance measures that align with our high standards and hold our vendor accountable, when necessary.”
Massachusetts Partnership officials declined to be interviewed, citing ongoing litigation and the need to protect patient privacy. But the company issued a general statement strongly defending its work at Bridgewater.
“At all times, our staff diligently work to comply with all regulations and statutes that govern care of their patients, as well as national standards,” wrote Steven H. Wheeler, the chief executive officer at the Massachusetts Partnership and president of MHM Services.
Wheeler pointed out that the 325-bed medium-security prison is the only one in the state that accepts mentally ill patients that require “strict custody,” with many of them presenting “very complex and challenging mental health, medical, legal, and situational issues.” Burns, for instance, had strangled another inmate during a psychotic episode shortly after being admitted.
Despite the challenges, Wheeler said, Bridgewater’s staff is making enormous progress in reducing the use of isolation rooms and physical restraints. The staff has cut its use of restraints by 90 percent this year, Wheeler said.
But the recent changes at Bridgewater — and Governor Deval L. Patrick’s proposed reforms, including increasing its clinical staff — are small consolation to the families of Messier, Burns, and Correia, who complain that Bridgewater officials have treated them with indifference.
Not one of the families has received a formal apology, for example. And Bridgewater officials have yet to respond to a recent letter from John and Margaret Burns asking for records related to their son’s death, or to a similar letter from Carmela Correia, Paul Correia’s 73-year-old widowed mother.
“The pain I am going through I can’t describe to anyone,” Carmela Correia said. “I just want answers. I need closure.”
‘He was seeing spiders’
Bradley Burns was already a patient at Bridgewater State Hospital in 2009 when Joshua Messier died while strapped to a bed, his face turning blue as guards stood by idly for several minutes. The first two nurses on the scene weren’t much help either, both leaving Messier’s cell without administering CPR, surveillance video shows.
But the fiasco brought no change in Burns’ 23-hour-a-day confinement to a bed in five-point restraints. The correction commissioner at the time, Harold W. Clarke, rejected the medical examiner’s finding that Messier was a victim of homicide, and no one was disciplined despite video showing guards roughly handling Messier, and an investigation by the Disabled Persons Protection Commission that found two guards were responsible for Messier’s death.
Indeed, over the next five years, Bridgewater clinicians employed physical restraints on inmates even more frequently, records show.
MHM clinicians never came up with an effective treatment plan for Burns, a Northeastern University honors graduate who had owned two physical therapy clinics and drove a BMW before schizophrenia left him beset by delusions and auditory hallucinations that sometimes caused him to lash out violently.
While at Bridgewater for a psychiatric evaluation after a 2004 hostage-taking incident at a McDonald’s restaurant, Burns became convinced that a fellow patient posed a mortal threat to him, and strangled him with a T-shirt.
“He said he was seeing spiders on the other inmate,” said Grossberg, Burns’s attorney. “That’s what you call a paranoid schizophrenic, a true one.”
For more than a year, clinicians and prison guards kept Burns in solitary confinement, allowing visits from doctors and nurses, his parents, and his lawyer.
Eventually, clinicians allowed Burns to mingle with other patients on a limited basis. But by 2008, Burns began hearing voices more frequently and appeared intent on taking his own life, often diving from the top of pieces of furniture headfirst onto the floor.
In 2009, after Burns tried to gouge out his own eyes, staffers isolated him more aggressively. Doctors ordered him held in five-point restraints, with protective head, eye, and hand gear. Eventually, they refused to let friends see him, and limited his parents to one-hour visits. Though Burns was initially provided with reading materials and allowed to listen to the radio, his parents and his attorney said even those privileges were soon withdrawn.
The result was a ghoulish spectacle that alarmed even some Bridgewater staffers: a man completely immobilized for months on end, deprived of virtually any connection with others.
Stuart Grassian, a Newton psychiatrist and an expert in the use of isolation in prisons, said he had never heard of an inmate or patient being immobilized 23 hours a day with so little access to the outside world.
“There is no explanation for depriving him of these things other than that it was punitive,” said Grassian. “It feels almost medieval.”
Even though Burns was a difficult patient, convinced that the CIA was controlling his mind, Grassian said, clinicians should have done more to engage him in activities that would distract him from his delusions and the voices in his head, and connect him with reality.
“Without that, it would perhaps be impossible for him to recover, no matter what medication they were giving him,” he said.
Dr. Kevin M. Monahan, a Boston Medical Center cardiologist interviewed by the Globe, said that the clozapine prescribed to Burns as well as his long hours completely immobilized in restraints could have increased the chances that he would suffer an irregular heartbeat, which the medical examiner concluded was the most likely cause of his death.
Monahan also said that restraints, in and of themselves, can cause stress, leading to elevated heart rates and blood pressure, particularly when a patient is agitated, and that this stress may trigger other, previously undiagnosed risk factors.
“If you’re putting someone in restraints, that’s a big physical stress on the body, and these undiagnosed problems may well come to light,” he said.
It’s difficult to tell whether Burns could have been saved the morning he died, in part because Bridgewater officials never conducted a mandatory review in which a panel of clinicians, usually including an outside expert, would have studied the circumstances surrounding his death.
But one analysis filed with a private organization that accredits health care facilities shows that the emergency response when Burns lost consciousness was flawed. Department officials admit in the analysis that the response by staff was uncoordinated and inefficient, and that necessary “medical equipment was not at bedside.” It also noted that on-site emergency response training for staff had been canceled, without further explanation.
Margaret and John Burns said that, more than four years after their son’s death, they remain confounded by the actions of Bridgewater prison officials and the treatment provided to their son by Bridgewater doctors and nurses.
“In this day and age, why did our son have to suffer so much?” Margaret Burns said.
‘He would not have died’
When Paul Correia arrived at Bridgewater State Hospital on a Friday evening in August of 2013, the schizophrenia patient was screaming, threatening prison guards, and refusing to leave the van that had moved him from the Bristol County House of Correction.
Three days earlier, Correia had suffered a broken nose and other injuries during a fight with Westport police following a traffic accident — injuries that, along with his obvious obesity, put him at increased risk for blood clots if he were to be immobilized.
For the last several years of his life, Correia, whose mental illness made it difficult for him to hold a job, had lived with his mother and his beloved Spotty, a white American bulldog with a large black patch splashed across his right eye. When he wasn’t listening to heavy metal music in his basement bedroom, Correia would spend hours in the garage, lovingly restoring a vintage Chevrolet Chevelle SS.
But the voices that often intrude into the minds of men and women afflicted with schizophrenia would always return, often leading to violent outbursts involving members of his extended family, suicide attempts, visits from the police, and trips to the nearby Corrigan Mental Health Center in Fall River.
“Whatever the voices told him to do, he did it,” his mother, Carmela Correia, recalled.
She last saw her son while sitting in the front row at Fall River District Court five days before his death, as he repeatedly interrupted the judge during his bail hearing on motor vehicle violations and charges of assaulting police officers following his accident, which apparently began with his psychotic episode.
The judge ordered Paul Correia, who arrived shirtless, held on $2,000 bail, which his mother was not prepared to pay on short notice, a fact that still haunts her.
“If I knew I had to have the money, my son would be alive today,” she said.
At the Bristol County House of Correction, Correia refused to take antipsychotic medications and his mental health deteriorated, until officials brought him before a second judge, who sent him to Bridgewater State Hospital.
When Correia arrived, a Massachusetts Partnership doctor immediately ordered guards to take Correia to a cell and place him in four-point restraints, strapping his wrists and ankles to a bed.
At the time, the company had a detailed five-page policy on the care of patients in restraints, including regular monitoring of their vital signs. But it said nothing about precautions for patients facing heightened health risks.
Department of Correction records are not clear on whether Bridgewater clinicians knew Correia had been hospitalized twice after his fight with police, although they had noted he had bruises and scratches on his face and extremities.
Later that night, after Correia had agreed to take antipsychotic medications, Massachusetts Partnership clinicians found him to be “quiet, calm, and alert,” according to Bridgewater records. Yet they continued to hold him in restraints “as a new admission,” despite a state law that allows restraints only to address “the occurrence of, or serious threat of, extreme violence.” By Monday morning, on Aug. 26, 2013, Correia was dead.
The state medical examiner found that he died from a blood clot that developed in one of his legs and passed into his lungs, a condition known as a pulmonary embolism that may have been brought on by the use of four-point restraints and exacerbated by Correia’s weight, according to the autopsy. Correia was 5 feet 7 inches tall and weighed 263 pounds.
“The autopsy suggests that, were it not for the restraints, more likely than not the pulmonary embolization would not have occurred and he would not have died,” said Grassian, the Newton psychiatrist, who reviewed Correia’s autopsy at the request of the Globe.
Correia was the third mental health patient in just over four years to die at Bridgewater after being placed in restraints, but state records suggest that correction officials had learned little from their earlier experiences.
That is at least partly because, after the deaths of Messier and Burns, in 2009 and 2010, department officials chose not to conduct a detailed review , even though such a review is required by department policy after a patient’s demise.
An internal investigation ordered by Public Safety Secretary Andrea Cabral later faulted Bridgewater officials for failing to complete a mortality review in the Messier case.
But in the case of Correia, who died just as the Globe began investigating the circumstances surrounding Messier’s death, department officials chose to undertake the required Quality Assurance Mortality Review and found significant flaws in the performance of the Massachusetts Partnership.
An outside medical expert who took part in the review, Debra Poaster, the medical director at the Brandeis University Health Center, raised questions about the use of four-point restraints on Correia, noting that anyone subjected to that treatment would stand an increased chance of developing blood clots simply by virtue of being immobilized.
In the review, completed in May, Poaster also raised questions about clinicians who may have failed to keep adequate records of Correia’s vital signs, or to take action after discovering that the level of oxygen in his blood was low.
In addition, Poaster said the medical staff’s poor record- keeping raised questions about whether clinicians had exercised Correia’s limbs while he was being held in restraints, a policy requirement designed to reduce the risk of blood clots.
Department officials asked the Massachusetts Partnership for a comprehensive plan to address the shortcomings identified during the review, which the company has provided, while also sharply reducing the use of restraints.
However, a series of department audits conducted over the summer show that the company has continued to approve the use of restraints and isolation in a manner that does not appear to follow state law, by failing to document the emergency conditions required in order to continue holding a patient in restraints or isolation.
Partnership’s state contract
Less than two months before Correia died, the Massachusetts Partnership took over medical and mental health services for the entire Massachusetts prison system. It was the only company that proposed providing both medical and mental health care for the 10,500 inmates at the state’s 18 facilities.
The company was the low bidder, which was a key factor in the contract award, according to a Correction Department memo obtained by the Globe from Prisoners’ Legal Services, a nonprofit that advocates for the rights of state prison inmates.
The department also believed that the Massachusetts Partnership would continue to reap cost-saving efficiencies because it was taking on both medical and mental health responsibilities, and because its parent companies, MHM and Centene Corp., each have experience providing health care to the uninsured and underinsured.
“Through this partnership, MPCH will have the ability to bring sophisticated health care management systems that are currently being used in the community and apply them to the prison setting,” said Weiner, the former department official, in the memo.
But the audits of the Massachusetts Partnership’s recent performance at Bridgewater — which found poor quality medical care and the questionable use of restraints and seclusion — and the fines levied by the Correction Department for failing to meet staffing requirements raise questions about how well the company is meeting the terms of the five-year contract.
And advocates for the inmates say the quality of care has been a disappointment.
“The overriding concern appears to be how to justify the denial of medical and mental health care, rather than how to provide appropriate treatment,” said Leslie Walker, with Prisoners’ Legal Services.
“Prisoners with treatable conditions are ignored or undertreated for weeks or months,’’ she said, “leading to needless suffering, costly lengthy hospitalizations, and often dire or even fatal consequences.”
But, in its statement, the Department of Correction praised the Massachusetts Partnership, asserting that the company “has worked collaboratively with the department to improve the treatment given at Bridgewater State Hospital.”